Final evaluation of the child survival IX project in the Chaco of Bolivia (volume 1 -- report)

The project achieved the vast majority of its objectives and ranks in the superior category of CS projects. Significant advances have been made in: the use of services for diarrheal disease control and pneumonia; mothers' knowledge of dehydration and the signs of pneumonia; the percentage of children registered in the growth monitoring program and weighed in the past 6 months; exclusive breastfeeding for 6 months and early lactation just after birth. Also, the provision of two doses of Vitamin A to children aged 12-24 months has improved, and rates of malnutrition and inadequate growth have declined dramatically; this is unusual for CS projects without a supplemental feeding program. There have been marked increases in the number of women receiving two or more pre-natal visits and in delivering with the help of trained birth attendants. On the down side, more work needs to be done regarding immunization coverage. The new project area in Entre Rios has shown a dropoff between the first and third doses of DPT and polio, as well as in the completion of the full series of childhood immunizations by age 24 months. However, much of this apparently low coverage appears to be due to loss of the immunization card. The high percentage of indigenous Amer-Indian people in this zone who do not speak Spanish and who are not familiar with the use of the card means that impact surveys based on the existence of the card will show artificially low coverage rates. The project's impressive achievements stem from several factors: the use of social investigation and social marketing techniques; completion of the project's training and supervisory objectives for all levels of health care workers; the involvement of trained traditional healers, traditional birth attendants, and a small army of village-level health volunteer promoters that has expanded coverage to areas without health posts; better organization of services at health centers and posts; continuity of project staff; major investments by the Government of Bolivia in constructing and equipping health facilities where none existed before; enactment of the Law for Popular Participation, which has put fiscal resources in the hands of local community governments; and the commitment of local communities and of the National Health Service to the project. Sustainability at the 80-90% level has occurred in the older project zones where services have been active for 9-10 years. However, in the new project zone of Entre Rios where service has only been active for 4 years, sustainability is only at the 50-- 60% level, even though excellent gains have been made in service coverage. The experience gained early on in this project has contributed to improved coverage in the new zone, but sustainability in an entirely new area takes many more years than originally envisioned. Esperanca is now expanding into Camargo, a highland indigenous area with Aymara and Quechuan-speaking Indians that has a quite different social and cultural setting than the lowland Indian population of the Chaco. As for Entre Rios, an additional 2-3 years of TA would improve sustainability in this project zone. Lessons learned are as follows: (1) The social investigation and social marketing techniques using qualitative assessments are as essential to program success as is technical capacity building. It is as important to understand cultural perceptions of health and to design educational and mass media approaches to address them as it is to train health workers in technical services. (2) Administrative organization of the health services at all levels is a key ingredient to success, especially at the point-of-service level. Major gains were made only in the last stage of the project, when supervisory visits were able to focus on detailed administrative organization at the health post and center levels. This is increasingly important as the focus shifts from CS to integrated management of the sick child. (3) Critical elements of success include effective supervision; joint planning, implementation, and evaluation of program activities between project staff, Ministry of Health personnel, and community counterparts (including NGOs wherever possible); the use of mass media; and feedback of information to the communities.