Evaluation of the essential services for health in Ethiopia (ESHE) program

Interim evaluation covers the period 8/95-5/98. Overall, ESHE is supporting national health policy as expressed in the Health Sector Development Program (HSDP) and is contributing to its own strategic objective of increased use of PPHC services. With relatively minor modifications, ESHE is likely to have a favorable, long-term impact on the health status of the population of Ethiopia through its increased budgetary allocations for health, particularly for PPHC; more effective management and planning; and direct support for increased access and use of essential services, such as immunization, maternal/child health/family planning (MCH/FP), STI/HIV/AIDS control, and curative services. The prospects are favorable for ESHE to build on advances in improved services at the central level and in focal project areas and to have such advances replicated in other regions. Progress has been made in FP, including condom social marketing, through effective NGO programs, and in PPHC enhancement through capacity building and systems development in the project focus area, the Southern Nations, Nationalities and Peoples Region (SNNPR). On the down side, progress in health care financing (HCF) has been constrained by the late start-up of the project and by delays in establishing formal counterpart structures, including the set up and staffing of the HCF Secretariat. Additionally, there is insufficient "ownership" of ESHE by the Government of the Federal Democratic Republic of Ethiopia (GFDRE) and in particular by the central Ministry of Health (MOH), although this does not appear to be an issue in the SNNPR. The situation at the central level may stem from communication problems on all sides, which are creating a feeling that the central departments are being "left out" of the project's planning and implementation. USAID's system of project funding may also be contributing to the lack of ownership. Because of present USAID policies, it is difficult to pass bilateral funds directly through the GFDRE; substantial additional investment in management and accounting capacity would be needed to facilitate this process. Although progress is being made in strengthening the relevant systems at the central and regional levels, there does not appear to be a more cost-effective option for the immediate future than using TA contractors or other mechanisms to facilitate and account for the flow of funds. Other salient issues are as follows: (1) Several MOH departments expressed a need for other capacity-building activities at the central level, such as information, education, and communication (IEC) activities and supplies management (essential drugs and FP commodities). These are two essential components of the HSDP that will directly affect ESHE's strategic objective of increasing use of health services. (2) ESHE could have greater impact and improve communications and coordination, particularly at the central level, if the technical advisors of the project's Cooperating Agencies (CA) were located within the MOH and had well-defined terms of reference and job responsibilities agreed upon by all parties. For maximum impact, the Basic Support for Institutionalizing Child Survival (BASICS) project's HCF advisor should be located in the MOH's Projects and Planning Department with close links to the Health Services and Training Department. (3) In the SNNPR, where progress has been more visible, the Regional Health Bureau has expressed its general satisfaction with achievements. However, TA for capacity building and systems strengthening in the SNNPR will be required beyond the life of the current contract. (4) The performance indicators for some components and for intermediate results relating to ESHE's results packages may be too numerous and too general, and it may be difficult to manage and measure progress adequately. Includes recommendations. (Author abstract, modified)