Final evaluation of the maternal child health/family planning project, Rwanda (696-0113)

External evaluation covers the period FY81-8/87. Despite financial and socioeconomic constraints, the project made considerable progress and the overall environment for FP has grown more favorable since project inception. Mass education was the most successful component, with 30% of Rwandan women exposed to FP information through radio or direct contact with ONAPO personnel. Research activities were also successful, resulting in a data base for use in forming population policy and increasing public awareness of the country's severe demographic crisis; the National Fertility Survey was a particularly important project output. Components to improve service delivery were less successful. MINISAPASO capability is greatly underdeveloped, largely because FP responsibility is assigned to a low organizational level within the Ministry. Although a great deal of training in IEC and FP service delivery took place, only 140 medical assistants and nurses received some form of FP training, compared to the target of 250. Moreover, the staffing of health centers lacks uniformity and supervision. The construction component was fraught with delays and cost overruns caused by inadequate planning, an overly costly model for rural health centers, and inadequate attention to the skills of host-country contractors. Design problems will hamper effective utilization of both the training center and the health/nutrition centers. Purchasing and management of commodities were inadequate with respect to financial controls and contraceptive stocking and storage. Input delivery was also problematic, as flaws in financial tracking and planning were identified relatively late, and the position of ONAPO Financial Manager was vacant throughout most of the project. Among other financial problems, construction's share of funds were increased at the expense of more central budget items, notably, TA and local costs of activities. An array of socioeconomic issues continue to hinder contraceptive acceptance and need to be addressed in any future project. These include, inter alia, demand for child labor (e.g., for carrying water, and agricultural activities), misconceptions about the effects of contraception, weakness of the professional midwifery tradition, resistance among health professionals to community-based contraceptive distribution, strength of the Catholic Church and its importance in the health sector, low levels of literacy and schooling, logistical constraints on access to service delivery sites, and biases against providing FP services to unmarried and childless women. Overall recommendations are to sustain the momentum the government's population policy reform, continue mass education, and extend the role of the private sector (especially Protestant PVO's) in service delivery.