Health systems vitalization

Evaluation covered the period 9/83-4/87 and was based on site visits and interviews with USAID/ES, MOH, and TA staff. In the first years of the project, implementation was impeded by the war, a failing economy, the MOH"s administrative weakness, underestimation of the amount of TA needed, an unusual degree of direct Congressional involvement, and slowness of the A.I.D. procurement process. The earthquake which struck San Salvador in 10/86 was a setback, and the PACD was extended to 7/31/87 as a result. Nonetheless, the health care capacity of the MOH has been markedly strengthened by the pharmaceuticals, supplies, vehicles, and medical equipment provided by the project, and by infrastructural improvements, including warehouses and workshops for repair and maintenance of vehicles and biomedical equipment. The vehicle maintenance and malaria components were the most successful. Gains were also made regarding the selection, procurement, distribution, and warehousing of pharmaceuticals and medical supplies, but further improvements are needed. The computerized management information system just began to operate in 1987, and further training is needed for both users and operators. Progress was more difficult in biomedical equipment maintenance and in the training aspect of emergency medical services, and the evaluation recommended that private sector alternatives be explored in these areas. The follow-on project should place more emphasis on institutional development (as opposed to resource transfer), management and planning improvements, training of mid-level managers and technicians, and improved services at the level of health posts, units, and communities. Several lessons were learned. (1) Institution building is not accomplished with resource transfer alone, and it takes time; in this case, 3-5 years was clearly insufficient. (2) Continuity of TA has a positive effect, especially for institution building. (3) MOH policy changes, while time-consuming, but are of key importance; policy efforts should not be sacrificed to external pressures for quick results. (4) Cooperation among all parties should begin during the design stage. (5) Lack of a full assessment of MOH personnel skills was a major constraint; training should have been a priority. (6) Care must be taken to assure that lower-level facilities obtain sufficient resources. (7) Project documents had detailed line items that required continual modification. It would be better to prepare illustrative budgets and permit changes of up to 30% by the host government and the A.I.D. project manager, without the necessity of time-consuming PIL"s.