Evaluation of the primary providers' training and education in reproductive health (PRIME) project

The project has successfully completed, or is on track to complete, specified deliverables. It has also made significant strides in emphasizing the key results areas negotiated with USAID during 1997 and 1998. Primary accomplishments include: reaching new cadres of RH primary providers; expanding RH services and the mix of services; decentralizing training; focusing on quality through guidelines, training, materials, monitoring and supervision, counseling, and client-provider interaction (CPI); experimenting with innovative learning approaches; building training and resource planning capacity; and initiating a systems approach to training. In the area of technical leadership, PRIME has: played a major role in decentralizing post-abortion care (PAC) services and increasing access to services closer to where women live; made an important contribution in linking policies, guidelines, and standards with training and the follow-up of provider performance; and promoted the performance improvement approach (PIA) in provider training. Important strides have been made in training primary providers. A major accomplishment has been to decentralize training and to extend high-quality performance-based training into new areas of RH and to new levels of service providers. PRIME has prepared curricula and training manuals and trained trainers for auxiliary nurse midwives, indigenous medicine providers, and traditional birth attendants. A second major accomplishment is the development of capacity for systematic follow-up and monitoring of training, though follow-up visits often focus on data collection rather than on improving performance. The major problem with PRIME's training programs is that, in reaching out to new cadres and new RH areas, training and follow-up is staff-intensive, expensive, and difficult to sustain. Other problems include: lack of a comprehensive strategic plan for training, i.e., one that includes analysis of alternative training strategies, analysis of cost, identification of appropriate exit strategies, trainee selection criteria, and pre-training service performance; insufficient development and testing of alternative learning approaches; lack of focus on pre- service institutions; insufficient attention to men and adolescents as populations with special needs; and limited integration of emergency contraception, female genital cutting, or sexually transmitted infection (STI) prevention in training curricula. PRIME has shown consistent commitment to the maximizing access and quality (MAQ) strategy, which features: a focus on essential primary personnel; integration of selected RH interventions; addressing provider needs and performance beyond training; policy activities; attention in training to counseling and other CPI skills; replicable and sustainable systems, approaches, and materials; and culturally appropriate strategies. PRIME's limited definition of its technical advisory role may foster a "disconnection" between PRIME's goals and its effectiveness in the field. After delivering TA, PRIME often takes a "hands off" approach, encouraging partners to take a major role in implementation. While fostering local capacity building, this strategy sometimes leads to inadequate or inappropriate monitoring of progress in the field. Despite PRIME's attempts to strengthen capacity at all stages of project development, the sustainability of many training systems remains vulnerable. In particular, emphasis on systems approaches and performance improvement demands that greater attention be paid to the development of planning and data-based decision-making skills. Also, although monitoring and evaluation activities are carried out in virtually every PRIME subproject, evaluation indicators and monitoring instruments are not always used effectively. Finally, PRIME publications fill an important niche by providing baseline materials for the development of more specifically targeted publications. All the materials reviewed were of good quality, but seemed to be written for a very sophisticated user. Also, their language level often makes them difficult to use. PRIME needs to document its accomplishments, successful innovations, and lessons learned in a usable and attractive format. (Author abstract, modified)