Evaluation report, Project Concern International, Belize : Toledo primary health care project

External evaluation covers the period 1/83-9/86 and is based on site visits and interviews with Ministry of Health (MOH) officials and beneficiaries. The project has met some of its targets, but many problems remain. On the positive side, PCI has: (1) shown that CHW's can increase rural access to some basic health services and effectively help nurses in outreach and mobile health clinics; (2) modified its training during the course of the project to make it more relevant, and produced a manual which clarifies the roles/relationships of health workers; (3) developed a functioning cross-sectoral District Health Team; (4) developed some coordination with related community programs; (5) established village health committees (VHC's), although not all are functional; (6) tried to ensure that a Belizean will take over project administration, and that PHC is given more political and financial support at the national level; and (7) completed one health survey to identify actual health problems, with others planned or underway. The major obstacle to creating a self-reliant PHC system is lack of host government commitment. Although the MOH has a stated policy of priority for PHC and has developed a National PHC Committee, its support to the project has been inadequate. Prospects for sustainability are dim as the supervisory structure for CHW's depends largely on foreign advisors and it is unlikely the MOH will be able to supply enough nurses as supervisors. Rural nurses' posts are unfilled throughout the country and turnover is high. Most VHC's seem weak, ineffective, or uninterested; apparently MOH/PCI community development and follow-up have been insufficient. As a result, there is only sporadic village support for the CHW's and villagers are generally unwilling to pay for CHW services. Also, the project's training plan was too ambitious and has been scaled back - of the 50-60 CHW's originally to be trained, only one group of 15 has been trained (and only 9 have remained in the field), and another group of 15 will complete training in 1986. Other difficulties include: (1) an inadequate and inconsistent information system for reporting CHW activities - baseline and benchmark surveys are needed; and (2) inadequate logistic, supply, and referral systems. The project demonstrates the inevitable cultural, economic, and political barriers that slow the development of new PHC systems - even in a politically stable and relatively homogenous nation such as Belize.