Final evaluation of REACH I (resources for child health project)

Because of the subsequent development of REACH II before the completion of the REACH Project, this evaluation will refer to the REACH Project as REACH I. Nine cognizant technical officers (CTO's) were responsible for REACH I during its 5 years and, making a virtue of necessity, the project was permitted to evolve responsively and progressively. REACH I was not subjected to bureaucratic inaction as could have been the case with the discontinuity of CTO's. HCF is an increasingly fundamental component of sustained health services worldwide. HCF has evolved from a minor component of REACH I into a new, separate project, Health Financing and Sustainability. EPI was not inhibited by the growth of HCF activities during this phase of REACH I. Indeed, demand for EPI services likewise evolved into a new project, REACH II, that includes an additional component designed to reduce the impact of acute respiratory infection upon child survival (CS). REACH I was a successful project. Most of the people the evaluation team interviewed thought it had been flexible and responsive to the needs of regional bureaus, and especially to mission and host country requests. Consultations were generally of high quality and performed in a timely fashion. While REACH I was a centrally funded project, USAID missions were allowed to "buy-in" using their funds. This mechanism successfully stimulated project growth and evolution. Because of buy-ins, the budgeted ceiling of the allocated funding level was achieved much sooner than anticipated, resulting in REACH I having to ration requests for service. The goal and objectives of REACH I coincided closely with the CS endeavors of the World Health Organization (WHO), the United Nations Children's Fund, PVO's, and others. Close collaboration, coordination, and communication should have been important aspects of project implementation. Unfortunately, the discontinuity of CTO's, the paucity of staff resources, and the inadequacy of CTO travel funds constrained the role of S&T/H in collaborating with other agencies and managing and coordinating REACH's CS endeavors. The effectiveness of S&T/H as a major player in international CS activities should not be compromised; the resources needed for adequate A.I.D. managerial oversight should be committed. The contractor, John Snow, Inc. (JSI), appears to have performed well despite these problems. As only one of the many organizations involved in EPI, REACH I had to identify a role that would complement and supplement the activities of other EPI donor organizations. REACH I emphasized cost-effective delivery, strengthening information systems, and improved monitoring of immunization coverage. It also focused on working with NGO's and PVO's to enhance their capacity to use sound public health practices in their delivery of EPI services. REACH I significantly enhanced the training of health workers and increased the production and dissemination of information materials. Especially noteworthy was the production of the popular field guides, EPI Essentials: Guidelines for Identifying and Implementing HCF Activities and Costing of Health Services Delivery Guidelines. In collaboration with WHO, REACH I installed and customized a computerized EPI information system in nine countries. REACH I also developed a standardized methodology for EPI costing with WHO, and tested a nonreusable syringe and needle to prevent the transmission of hepatitis B and AIDS. REACH I stimulated the development of new ideas and helped initiate policy dialogue, including a renewed commitment to eliminate neonatal tetanus, a leading killer of infants. Urban areas with their growing population of underserved children are a special challenge to effective EPI administration. REACH I called attention to and, through REACH II, continues to address this problem. Initially, USAID had anticipated that HCF would constitute only a minor part of REACH I system support for primary health care technology. Instead, USAID missions submitted so many requests for HCF technical assistance that initially REACH I could barely meet the demand. As a result, significant quantities of resources were dedicated to health financing activities in such areas as accounting, social insurance schemes, user fees, health maintenance organizations, hospitals, primary health care, and systemwide reform. At the inception of REACH I there was a shortage of HCF experts, particularly within PVO's. Thus, it took JSI and its HCF subcontractors some months to develop PVOs' HCF capacity. Currently, however, JSI contributes positively to the worldwide HCF effort. REACH I represents an ongoing development program, not a distinct and isolated project. The evolution of priorities during the course of REACH I changed the project's components in a positive and desirable way. Efficient, effective management is required to ensure the flexibility, responsiveness, and change characteristic of successful programming. Indeed, without the continuity of a CTO who possesses the requisite support, technical, and managerial skills, the risk of project failure increases dramatically. REACH I owed its success largely to the aptitude and professionalism of JSI and its subcontractors. USAID must strengthen the capacity of its CTO's to exercise the kind of leadership required to ensure success. (Author abstract)